1. Technical Field
The present invention relates in general to a pharmacy benefit management system and method of using it. The invention more particularly relates to a system which facilitates the monitoring of prescriptions authorized by a medical group according to a novel method.
2. Background Art
The health provider system known as managed care was created to provide health care at a reasonable cost. Under managed care, subscribers of a health care plan received health care at reduced rate by controlling the health care costs of the entire pool of subscribers. One such health care plan was the health maintenance organization ("HMO") which controlled health care costs, in part, by contractual arrangement with individual physicians. In exchange for agreeing to provide health care services for the subscribers of the HMO, the physicians would be reimbursed by the HMO for the health care services provided.
In an effort to obtain more leverage in negotiating agreements with the HMOs, groups of physicians became associated with one another as medical groups. Such medical groups were formed as corporations, partnerships, and other associations to enable each physician in the medical group to obtain more patients, higher reimbursements, etc. from the HMOs than a single physician could obtain without the medical group.
A component of managed care was the capitation of a pharmacy benefit. The capitation referred to a fixed amount of money paid by the health care plan to the medical group to manage the costs of prescription drugs for subscribers of the health care plan (the patients of the medical group physicians). The amount paid by the health care plan was determined on a per subscriber, per month, basis. In the event the costs of drugs prescribed by the medical group are less than the capitation of the pharmacy benefit, the medical group realizes the difference between the capitation and the actual drug costs as a pharmacy benefit profit. However, if the costs of the prescribed drugs exceeds the capitation, the medical group was indebted to the health care plan for the difference between the actual drug costs and the capitation, and the medical group realized a pharmacy benefit loss.
It has been difficult to monitor the drugs actually prescribed by the physicians of the medical group to enable the medical group to identify the prescribing activity of the physicians to help predict the expected costs for the actual drug costs. Furthermore, the actual drug costs could not be determined with a high degree of certitude, since the costs for the drugs prescribed could vary, depending upon the pharmacy where the drugs were obtained by the patient. Consequently, the actual drug costs relative to the pharmacy benefit capitation could not be determined with any real accuracy for the small medical group.
Therefore, it would be highly desirable to have a new and improved pharmacy benefit management system which can enable a medical group to analyze actual drug costs relative to a pharmacy benefit capitation for managing prescription drug activity. Such a pharmacy benefit management system should be relatively inexpensive, and convenient to use.
Also, it has been difficult to monitor pharmacy claims received from the pharmacies supplying the prescription drugs to the patients. As a result, the medical group could not determine if the patients were obtaining the drugs actually prescribed by the medical group physicians. Without the pharmacy claim information, the medical group was unable to determine the drugs, and the actual costs of the drugs, actually obtained by the patients.
Therefore, it would also be highly desirable to have a pharmacy benefit management system which would provide information regarding the drugs obtained, and their actual costs, to the medical group based on the prescription activity of the medical group physicians.